Form K.s.a. 59-2129 - Agency Consent To Adoption Of Minor Child
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2K.S.A. 59-2129
Agency Consent to Adoption
(7/1/05)
[CAPTION]
AGENCY CONSENT TO ADOPTION OF MINOR CHILD
, a (public)(private) entity having for its purpose
(name of agency)
the care and maintenance of children, is located in and authorized under the laws of the
State of
to place children for adoption, consent to the adoption and to stand
in loco parentis to such children until they are adopted or reach majority.
, is vested with the right to consent to the adoption
(name of agency)
of
, a minor child born
at
pursuant to
(name of child)
(date of birth)
(place of birth)
[a relinquishment executed by (the parents of the child)(the person in loco parentis to the
child)] [an order or judgment of the __________ Court of __________ County,
__________, a Court of competent jurisdiction]. Documents supporting the authority to
execute this consent are attached hereto.
does hereby consent to the adoption of
(name of agency)
(name of
by __________ resident(s) of __________ and does hereby surrender said child
child)
to said person(s) for the purpose of adoption.
has authorized __________ (Name of Authorized
(name of agency)
Representative) the undersigned, as the authorized representative to execute consents to
adoption on behalf of said agency.
[
hereby waives notice of the final hearing of the
(name of agency)
adoption.]
Date
(signature of authorized representative)
ACKNOWLEDGMENT BEFORE NOTARIAL OFFICER
STATE OF
)
) ss:
COUNTY OF
)
I, a notarial officer in and for the County and State aforesaid certify that
, known to me to be the same person whose name is subscribed to the foregoing
consent, appeared before me in person and acknowledged that the statements made in
the foregoing consent are true.
Dated
at
.m.
(signature of notarial officer)
(SEAL, if any)
title (and rank)
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